OBES SURG (29) 19:165 1611 DOI 1.17/s11695-9-14-5 REVIEW Metabolic/Bariatric Surgery Worldwide 28 Henry Buchwald & Danette M. Oien Received: 24 September 29 / Accepted: 7 October 29 / Published online: 3 November 29 # Springer Science + Business Media, LLC 29 Abstract Periodically, the state of bariatric surgery worldwide should be assessed; the most recent prior evaluation was in 23. An email survey was sent to the leadership of the 36 International Federation for the Surgery of Obesity and Metabolic Disorders nations or national groupings, as well as Denmark, Norway, and Sweden. Responses were tabulated; calculation of relative prevalence of specific procedures was done by weighted averages. Out of a potential 39, 36 nations or national groupings responded. In 28, 344,221 bariatric surgery operations were performed by 4,68 bariatric surgeons; 22, of these operations were performed in USA/Canada by 1,625 surgeons. The most commonlyperformed procedures were laparoscopic adjustable gastric banding (AGB; 42.3%), laparoscopic standard Roux-Y gastric bypass (RYGB; 39.7%), and total sleeve gastrectomies 4.5%. Over 9% of procedures were performed laparoscopically. Comparing the 5-year trend from 23 to 28, all categories of procedures, with the exception of biliopancreatic diversion/duodenal switch, increased in absolute numbers performed. However, the relative percent of all RYGBs decreased from 65.1% to 49.%; whereas, AGB increased from 24.4% to 42.3%. Markedly, different trends were found for Europe and USA/Canada: in Europe, AGB decreased Presented before the 14th World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders, Paris, August 27, 29. This work was supported by Synovis Inc. H. Buchwald (*) : D. M. Oien Department of Surgery, University of Minnesota, 42 Delaware St SE, MMC 29, Minneapolis, MN 55455, USA e-mail: buchw1@umn.edu from 63.7% to 43.2% and RYGB increased from 11.1% to 39.%; whereas, in USA/Canada, AGB increased from 9.% to 44.% and RYGB decreased from 85.% to 51.%. The absolute growth rate of bariatric surgery decreased over the past 5 years (135% increase), in comparison to the preceding 5 years (266% increase). Bariatric surgery continues to grow worldwide, but less so than in the past. The types of procedures are in flux; trends in Europe vs USA/Canada are diametrically opposed. Keywords Morbid obesity. Bariatric surgery. Worldwide survey. Trends. Gastric banding. Gastric bypass. Sleeve gastrectomy Introduction To understand the influence and impact of bariatric surgery, it is useful to assess the field periodically worldwide, at least every 5 years. More precisely, now that bariatric surgery has been recognized to be metabolic surgery, it is the state of metabolic/bariatric surgery that needs to be examined. The procedures for weight loss, whether designated as restrictive, restrictive/malabsorptive, malabsorptive, and others, or neuro-hormonal, all fall under the definition we proposed in 1978: "We define metabolic surgery as the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain" [1]. During the accelerating pandemic of global obesity, certain basic questions are being asked by the medical and the lay communities, as well as government and private funders of healthcare: how many metabolic/bariatric procedures are being performed, by how many surgeons, and where? Since
166 OBES SURG (29) 19:165 1611 there has been, and continues to be, a flux in the types of metabolic/bariatric procedures performed, a quantitative evaluation of operations done and the existing worldwide trends in procedures, seems to be called for as well. In 1998, as part of his 1997 Presidential Address before the annual International Federation of Surgery for Obesity (IFSO) Congress in Genoa, Dr. Scopinaro published the first global survey of metabolic/bariatric surgery [2]. In 24, we published a 5-year follow-up report titled: Bariatric Surgery Worldwide 23 [3]. We now present a subsequent 5-year follow-up and global perspective of metabolic/bariatric surgery over the past 1 years. Methods Questionnaire An email survey, consisting of three questions (Table 1), was sent to the leadership of the 36 IFSO nations or national groupings, and the three Scandinavian nations of Denmark, Norway, and Sweden (see acknowledgements). If necessary, these requests were followed by second and third email communications to obtain the data requested. Data Analysis Tabular and graphic presentations of the data received were prepared and certain derived data were calculated. For calculations of relative prevalence of specific procedures, weighted averages were used to compensate for the wide ranges of the number of procedures performed: P %Variable Number of Variable P Number of Variable Results Response Rate From the 36 IFSO nations or national groupings there were 33 responders (92%). Australia and New Zealand, Belgium and Luxembourg, and the United States of America (USA) and Canada were the three national groupings in the survey. With the participation of Denmark, Norway, and Sweden, the total global participating nations or national groupings numbered 36. Number of Operations Performed In response to the survey's first question Approximately how many bariatric surgery operations are being done in Table 1 Questionnaire 1. Approximately how many bariatric surgery operations are being done in your country yearly? 2. Approximately how many surgeons practice bariatric surgery in your country? 3. What is your estimate as to the relative percentages (adding up to ) distribution of bariatric operations in your country? open adjustable gastric banding laparoscopic adjustable gastric banding open vertical banded gastroplasty laparoscopic vertical banded gastroplasty open standard Roux gastric bypass (all technical variations) laparoscopic standard Roux gastric bypass (all technical variations) open long-limb and very long-limb gastric bypass laparoscopic long-limb and very long-limb gastric bypass open biliopancreatic diversion (Scopinaro procedure) laparoscopic biliopancreatic diversion (Scopinaro procedure) open duodenal switch laparoscopic duodenal switch open sleeve gastrectomy laparoscopic sleeve gastrectomy electronic pacers/blockers others your country yearly? the global total came to 344,221 for 28. The USA/Canada performed the vast majority of operations at 22,. An additional four countries or national groupings performed more than 1, operations in 28: Australia/New Zealand, Brazil, France, and Mexico; a further additional three countries or national groupings performed more than 5, operations in 28: Belgium/Luxembourg, Spain, and United Kingdom (Table 2). Number of Metabolic/Bariatric Surgeons In response to the survey's second question Approximately how many surgeons practice bariatric surgery in your country? the global total came to 4,68 for 28. The USA/Canada grouping had the most surgeons at 1,625. There were seven other countries or national groupings with more than 1 bariatric surgeons: Australia/New Zealand (118), Brazil (7), Chile (1), France (31), Italy (3), Mexico (15), and Spain (4; Table 3). Types of Procedures Performed The answers to the survey's third question What is your estimate as to the relative percentages (adding up to ) distribution of bariatric operations in your country? are
OBES SURG (29) 19:165 1611 167 Table 2 Number of bariatric surgery operations being done yearly Country Number of bariatric surgery operations Argentina 2,4 Australia/New Zealand 11,914 Austria 1,741 Belgium/Luxembourg 8,7 Brazil 25, Chile 1,5 Czech Republic 9 Denmark 2,4 Egypt 1,5 France 13,722 Germany 2,117 Greece 2,875 Hungary 3 India 1,216 Israel 2,5 Italy 4,842 Japan 8 Mexico 13,5 Netherlands 3,5 Norway 1,5 Peru 6 Poland 814 Portugal 1,323 Romania 837 Russia 75 Serbia 1 South Africa 4 Spain 6, Sweden 2,894 Switzerland 85 Turkey 5 Ukraine 19 United Kingdom 6, USA/Canada 22, Venezuela 1,242 Total 344,221 shown in Table 4. The most commonly performed procedures were laparoscopic adjustable gastric banding (AGB; 42.3%), and laparoscopic standard Roux-Y gastric bypass (RYGB; 39.7%). Considering all gastric bypasses together, i.e., laparoscopic and open standard, and laparoscopic and open long-limb and very long limb, the number of gastric bypasses exceeds AGBs (49.3%). In 23, there were no sleeve gastrectomies (SG) reported; currently, sleeve gastrectomies totaled 5.4% (5.1% laparoscopic,.3% open). Classification of Procedures Performed Laparoscopic vs Open Over 9% (91.4%) of world bariatric surgery was performed laparoscopically. Type of Procedure Categorizing the procedures on weighted averages into anatomic categories of purely restrictive (AGB, SG, vertical banded gastroplasty (VBG)), restrictive/malabsorptive Table 3 Number of surgeons practicing bariatric surgery Country Number of surgeons Argentina 5 Australia/New Zealand 118 Austria 52 Belgium/Luxembourg 82 Brazil 7 Chile 1 Czech Republic 15 Denmark 15 Egypt 8 France 31 Germany 75 Greece 45 Hungary 5 India 46 Israel 5 Italy 3 Japan 3 Mexico 15 Netherlands 45 Norway 25 Paraguay 2 Peru 15 Poland 2 Portugal 25 Romania 18 Russia 75 Serbia 5 South Africa 17 Spain 4 Sweden 9 Switzerland 4 Turkey 2 Ukraine 2 United Kingdom 6 USA/Canada 1,625 Venezuela 27 Total 4,68
168 OBES SURG (29) 19:165 1611 Table 4 Estimate as to the relative percentages (adding up to ) distribution of bariatric operations Distribution of bariatric operations Percentage Open adjustable gastric banding.1 Laparoscopic adjustable gastric banding 42.3 Open vertical banded gastroplasty.7 Laparoscopic vertical banded gastroplasty.4 Open standard Roux-en-Y gastric bypass 5.7 Laparoscopic standard Roux-en-Y gastric bypass 39.7 Open long-limb and very long limb gastric bypass.8 Laparoscopic long-limb and very long limb gastric bypass 3.1 Open biliopancreatic diversion (Scopinaro).3 Laparoscopic biliopancreatic diversion (Scopinaro).6 Open duodenal switch.2 Laparoscopic duodenal switch.6 Open sleeve gastrectomy.3 Laparoscopic sleeve gastrectomy 5.1 Electronic pacer/blockers <.1 Others.2 Total 1. (RYGB), and primarily malabsorptive (biliopancreatic diversion (BPD), duodenal switch (DS)). This distribution is 48.6%, 49.%, and 2.%, respectively. Looking at the percent of countries performing these procedures, calculated averages were 97% purely restrictive, 94% restrictive/malabsorptive, and 83% primarily malabsorptive. Global Trends World Regions Comparing the 5-year trend from 23 [3] to 28, all categories of procedures, with the exception of BPD/DS, increased in absolute numbers performed (Fig. 1). The relative percent of RYGB, however, decreased from 65.1% to 49.%; whereas, AGB rose from 24.4% to 42.3% (Fig. 2). SG entered the compilation, going from.% to 5.3%. The different world regions varied markedly in their respective 5-year trends. In Europe, though all procedures reported in 23 [3] increased in numbers in 28 (Table 5), the relative percent of AGB decreased from 63.7% to 43.2%, and the relative percent of RYGB increased from 11.1% to 39.% (Fig. 3). Though the total number of procedures also increased from 23 [3] to 28 in the USA/Canada (Table 6), the trends in the relative percentages of AGB and RYGB were diametrically opposed to those in Europe AGB increased from 9.% to 44.% and RYGB decreased from 85.% to 51.% (Fig. 4). Compa- 35, 3, 25, 2, 15, 1, 5, Number of Procedures Worldwide 146,31 95,257 344,221 168,597 145,563 35,712 18,98 7,81 6,845 8% 6% 4% 2% % Percentage of Procedures Worldwide 65.1% 24.4% 49.% 42.3% 4.8% 5.3% 2.% Fig. 1 Trends in number of procedures worldwide Fig. 2 Trends in percentage of procedures worldwide
OBES SURG (29) 19:165 1611 169 Table 5 Regional trend Europe Table 6 Regional trend USA/Canada Number Operations (Percentage) (Percentage) Change (Percentage) Number Operations (Percentage) (Percentage) Change (Percentage) Total 33,771 66,769 +97.7 RYGB 3,744 (11.1) 26,23 (39.) +595.1 AGB 21,496 (63.7) 28,843 (43.2) +34.2 BPD/DS 2,61 (6.1) 3,27 (4.9) +58.7 SG (.) 4,677 (7.) Total 13, 22, +113.6 RYGB 87,55 (85.) 112,2 (51.) +28.2 AGB 9,27 (9.) 96,8 (44.) +944.2 BPD/DS 4,635 (4.5) 2,2 (1.) 52.5 SG (.) 8,8 (4.) rable to Europe, SG entered the compilation, going from.% to 4.%. The data received from Latin and South America was insufficient to derive trends. The regional trend in the Asia/Pacific area, with an overall 376.9% increase in the total number of procedure (Table 7), was one of consistency from 23 [3] to 28 (Fig. 5). Total World In 1998 [2], there were 4, operations per year, in 23 [3], there were 146,31, and in 28 there were 344,221. The percentage increase, therefore, for the 5-year span from 1998 to 23 was 266%; for the 5-year span from 23 to 28 it was 135%; and for the 1-year span from 1998 to 28 it was 761%. Discussion In summary, we conducted a survey of bariatric surgery worldwide in 28. We canvassed 36 IFSO nations or national groupings, with a 92% (n=33) response rate, as well as the three Scandinavian affiliated nations of Denmark, Norway, and Sweden. Globally, 344,221 procedures were reported to be performed annually by 4,68 bariatric surgeons. The laparoscopic approach was preferred (91.4%) over open surgery. The most common procedures, 86.6% of the total number of procedures, by weighted percentages, were AGB (32.3%), laparoscopic RYGB (39.7%; open plus laparoscopic RYGB 49.3%), and laparoscopic SG (5.1%). The most common type of procedures by weighted percentages, were 48.6% purely restrictive (i.e., AGB, VBG, and SG), 49.% restrictive/malabsorptive (i.e., RYGB), and 2.% primarily malabsorptive (i.e., BPD/DS). The regional trends over the past 5 years of which procedures are predominantly employed markedly varied between Europe (decreased use of AGB, increased use of laparoscopic RYGB) and the USA/Canada (increased use of laparoscopic AGB, decreased use of RYBG). The data provided and derived from the three questions asked in this survey, immediately raise new questions, in particular: (1) Why, in the face of the accelerating world pandemic of obesity and morbid obesity, has the absolute rate of bariatric surgery decreased over the past 5 years (135% increase), in comparison to the preceding 5 years (266% increase)?; (2) why are there such diametrically opposed trends for laparoscopic AGB and laparoscopic 8% 6% 4% Percentage of Procedures Europe 63.7% 43.2% 39.% 8% 6% 4% Percentage of Procedures USA/Canada 85.% 51.% 44.% 2% % 11.1% 6.1% 7.% 4.9% 2% % 9.% 4.5% 4.% 23 1.% 28 Fig. 3 Trends in percentage of procedures in Europe Fig. 4 Trends in percentage of procedures in USA/Canada
161 OBES SURG (29) 19:165 1611 Table 7 Regional trend Asia/Pacific Number Operations (Percentage) (Percentage) Change (Percentage) Total 2,77 13,21 +376.9 RYGB 234 (8.4) 1,198 (9.1) +412. AGB 2,228 (8.4) 1,892 (82.5) +388.9 BPD/DS 83 (3.) 5 (.4) 94. SG (.) 545 (4.1) RYGB in Europe vs USA/Canada?; and (3) why has SG captured 5.3% of the global frequency of bariatric procedures? In response to the plateau in the number of bariatric procedures, this phenomenon cannot be explained by an overall lack of patients or exhaustion of the residual patient pool, since we operate on less than 1% of morbidly obese patients worldwide [3, 4], by the antiquated 1991 National Institutes of Health guidelines [5], and the annual global increase in the number of obese and morbidly obese individuals is about 1% [6]. It is also difficult to believe that only 1% of eligible individuals would elect surgery if it were available to them. The answer, therefore, must be denial of patient access to bariatric surgery by private or governmental payers for healthcare, lack of knowledge of the bariatric surgery option in some communities, misunderstanding about the management of obesity as a disease, and the continuing underlying prejudice against the obese. The differing operative trends between Europe and the USA/Canada can be stated to be due to disenchantment with AGB in Europe, a geographic area that has had a far longer experience with AGB than the USA/Canada and a comparable disenchantment with RYGB, the procedure with a longer history and greater experience of use in the 8% 6% 4% 2% % Percentage of Procedures Asia/Pacific 8.4% 82.5% 8.4% 9.1% 3.9% 4.1%.4% Fig. 5 Trends in percentage of procedures in Asia/Pacific USA/Canada. After all, over time, essentially all procedures lose some of their early achieved success and luster. Further involved factors may be the predictable craving for something regionally newer, the imposition of payer mandates, media-derived prejudices and biases, advertisement campaigns by the bariatric surgery industry, increased patient sophistication and use of websites, and, of course, relative regional economic advantages for bariatric surgeons. Regional trends and countertrends are probably divorced from valid value assessments and judgments. All the reasons that have been stated for the regional differences may well apply to the rise of SG independent of a DS. In addition, SG is one of the easiest and quickest of all bariatric procedures to perform [7]. Over time, this procedure will acquire long-term, follow-up data that will certainly influence its scientific assessment, and possibly influence its popular appeal. The weaknesses of this survey reside, in part, in the following: not all nations performing bariatric surgery belong to IFSO and were, therefore, canvassed, with the exception of Denmark, Norway, and Sweden; the response rate from the IFSO nations and national groupings was 33 out of 36 (92%), though the three absent nations perform relatively few bariatric surgery procedures; the patient and procedure numbers often were best estimates and not precise; and discrepancies in the provided data often required reassessment and conciliation of numbers. On the other hand, the strengths of this study reside in its objective and diligent approach to obtaining and correlating the data, as well as the fact that this survey provides the best available global estimates of bariatric surgery numbers and trends. What is needed in the future, in order to increase the accuracy, reliability, and universality of these essential global data would be for the establishment of an international IFSO registry with national compliance of all IFSO nations and national groupings, and the participation in IFSO of all nations performing metabolic/bariatric surgery. Acknowledgments We thank the following individuals and nations, or national groupings, for providing the data for this survey: Argentina, Carlos Casalnuovo; Australia, Harry Frydenburg; Austria, Karl A. Miller; Belgium/Luxumbourg, Jacques Himpens; Brazil, Arthur Garrido Jr, Thomas Szego; Chile, Juan Hepp; Czech Republic, Martin Fried; Denmark, Lars Naver; Egypt, Khaled Gawdat; France, Jean Mouiel; Germany, Rudolf A. Weiner and Christine Stroh; Greece, Konstatinos Konstatinidis; Hungary, Janos Bende; India, Pradeep Chowbey; Israel, Asnat Raziel; Italy, Luigi Angrisani; Japan, Isao Kawamura; Mexico, Luis A. Iturribarria; Netherlands, Mauritis de Braw and Jan Greve; New Zealand, Robert Fris; Norway, Rune Sandbu; Paraguay, Roque Duarte Pedro; Peru, Eduardo Valdez; Poland, Mariusz Wylezol; Portugal, António Sérgio; Romania, Nicolae Iordache; Russia, Yury I. Yashkov; Serbia, Milan Colic; South Africa, Tess van der Merwe; Spain, Antonio J. Torres; Sweden, Johan Ottosson; Switzerland, Markus Naet; Turkey,
OBES SURG (29) 19:165 1611 1611 Mustafa Taskin; Ukraine, Andriy Lavryk; United Kingdom, John Baxter; USA-Canada, Georgeann Mallory; Venezuela, Alberto Cardozo Pieranti. References 1. Buchwald H, Varco RL (eds.). Metabolic surgery. NY: Grune & Stratton; 1978. 2. Scopinaro N. The IFSO and obesity surgery throughout the world. Obes Surg. 1998;8:3 8. 3. Buchwald H, Williams SE. Bariatric surgery worldwide 23. Obes Surg. 24;14:1157 64. 4. World Health Organization. Obesity and overweight facts. http:// www.who.int/dietphysicalactivity/media/en/gsfs_obesity.pdf. Accessed 1 Sept 29. 5. NIH Consensus Statement. Gastrointestinal surgery for severe obesity. March 25, 1991; 27:9:1 2. 6. National Center for Health Statistics. Results from the 23 24 National Health and Nutrition Examination Survey (NHANES). http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/ overwght_adult_3.htm. Accessed 14 Sept 29. 7. Moy J, Pomp Al, Dakin G, et al. Laparoscopic sleeve gastrectomy for morbid obesity. Am J Surg. 28;196:e56 9.